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Pain Neuroscience Education (PNE)

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Original Editor - David Greaves, Lynette Fox, and Katie White as part of the Nottingham University Spinal Rehabilitation Project

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Introduction

Chronic Pain (CP) is a wide term commonly referring to a variety of conditions that present with pain that persists or recurs for more than three months, beyond usual recovery times for injury or illness. [1] [2] It is a very common and prevalent problem that affects the general population and most age groups worldwide. [3] [4] [5] [6] CP is a multifactorial disorder that is influenced by biology, psychology, environmental, and social factors.[7]

Pain Neuroscience Education (PNE) is a strategy that aims to teach patients to reshape their mindset and perception of pain despite these factors. It provides patients with a better understanding of their condition and motivates them to become active participants in their management programmes. What is interesting about PNE is that it has shifted the focus (1) from the traditional biomedical model to a biopsychosocial model of pain (2) from the clinician to the patient, changing the way we understand and manage chronic pain conditions and acknowledging its complex neurobiological and neurophysiological underpinnings.

Pain Neuroscience Education (PNE)

With respect to PNE, chronic pain is not viewed as a result of unhealthy or dysfunctional tissues. Rather, it is due to brain plasticity leading to hyper-excitability of the central nervous system, known as central sensitisation.[8] By educating patients about this process, one can understand why chonic pain may not be necessarily correlated to structural damage. As a result, the ultimate goal for PNE is to increase pain tolerance with movement (e.g., be able to perform exercise with mild discomfort), reduce any fear associated with movement, and reduce central nervous system hypersensitivity. In practice, this often includes the use of educational pain analogies, re-education of patient misconceptions regarding disease pathogenesis, and guidance about lifestyle and movements modifications that can be introduced.

There are two clinical indications for initiating PNE: [9]

  • the clinical picture is dominated by central sensitisation
  • illness coping mechanisms or poor illness perception is present
Effects of central sensitisation

Central sensitisation is when there is amplification of pain in the central nervous system. [10] It can result in hypersensitivity to stimuli, responsiveness to non-noxious stimuli, and increased pain response evoked by stimuli outside the area of injury, an expanded receptive field. [11] This can be assessed during the subjective and objective portion of a patient's evaluation. [12] The physiotherapist can determine what a patient's perception of their own pain is and how they cope with their pain.

Pain behaviors caused by central sensitisation

PNE aims to reconceptualise pain to patients with these four main points:

  • Pain does not provide a measure of the state of the tissues
  • Pain is modulated by many factors from somatic, psychological, and social domains
  • The relationship between pain and the state of tissues becomes less predictable as pain persists
  • Pain can be conceptualised as the conscious correlate of the implicit perception that tissue is in danger [13]

Application of PNE

The application of PNE is most useful as part of a combination therapy for chronic pain that includes physiotherapy intervention (including exercise therapy) and may or may not include pharmacological treatment. Its application is best applied by trained and skilled clinicians with experience in managing patients with chronic pain conditions. Overall, PNE serves as a method of reconceptualising a patient's perception of their pain experience, providing an avenue for reducing pain, disability and improving quality of life.[13] PNE puts the complex process of describing the nerves and brain into a format that is easy to understand for everyone regardless of age, educational level, or ethnic group.[14]

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[15]

Methods of PNE delivery vary but can typically involve around 4 hours of teaching that is provided to a group or individually, either in single or multiple sessions. [16] An interesting scoping review on PNE suggested that the patient's educational and and cultural level may play a role in PNE delivery and teaching / learning strategies, but there is insufficient evidence to date to inform the specifics of such programmes. [17] PNE consists of educational sessions for patients describing in detail the neurobiology and neurophysiology of pain and pain processing by the nervous system.[14] It is implemented prior to administering physiotherapy interventions with a verbal explanation. This is subsequently reinforced throughout the course of treatment to ensure proper carryover of reconceptualisation of pain during and after discharge from physiotherapy.

During the first educational session, the clinician should explain central sensitisation along with the use any of the following: pictures, booklets, pamphlets, metaphors, drawings, question/answer assignments, and neurophysiology pain questionnaires. Topics addressed include acute pain vs. chronic pain, how it evolves from acute pain to chronic pain, interpretation of stimuli to the nervous system, and external factors that may impact pain (such as anxiety, stress, depression, pain perceptions, and behavior). Patients are encouraged to read the handouts or brochures handed to them from the clinician at home.[9]

During subsequent sessions, the patient is encouraged to ask questions and receive clarification for any questions they may have about the neurophysiology of their pain. The clinician can address psychosocial aspects of a patient's pain during any visit. Some examples of clinically indicated advice that can be provided include advising the patient to stop worrying about their pain, reduce stress, implement relaxation techniques, and become more physically active. The treatment rationale should be provided throughout the patient's plan of care. Continually reinforcing and educating the patient regarding their pain physiology is recommended. The overarching goal is to motivate and encourage the patient to complete their treatment programme in order to achieve their functional goals. [9]

Figure 4 illustrates the content of PNE education sessions with patients [14]

Figure showing the content of PNE education sessions
Figure 4. displays the content of PNE education sessions

An example of a metaphor or story that can be used with patients is provided here: http://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/therapeutic-neuroscience-education.

Based on a large number of high-quality studies, it has been shown that educating people with chronic pain on the neuroscience of their pain produces immediate and long-term changes. PNE has been shown to have positive effects in reducing pain, disability, and psychosocial problems, improving patient's knowledge of pain mechanisms, facilitating movement and decreasing healthcare consumption.[18] Research highlights that PNE, by demystifying the biological and psychological aspects of pain, empowers patients to manage their condition more effectively and fosters a sense of control, which is crucial for long-term recovery. [19]

PNE for Chronic Musculoskeletal Conditions

Chronic MSK conditions with positive PNE results

Chronic musculoskeletal (MSK) conditions are often characterised by brain plasticity that leads to hyperexcitability of the central nervous system (central sensitisation). Figure 5 highlights chronic musculoskeletal conditions that may benefit from PNE, including osteoarthritis, fibromyalgia, pelvic pain, whiplash, lateral epicondylitis, and low back pain.[20][21][22]

Synthesis of quantitative and qualitative studies on the clinical effectiveness and patients' experience of PNE for people with chronic musculoskeletal pain (CMP) suggest that although PNE may facilitate patients’ ability to cope with their condition, it has not yet shown clinically significant decreases in pain, disability, kinesiophobia or catastrophising in the long term. [23] However, studies with long follow-up periods are still scarce. Patients need to tell their own story and feel heard, and this practice should be included in PNE programmes. The role of health care professionals skilled in PNE allows for pain reconceptualisation and therefore progress toward reconceptualisation should be monitored throughout, ensuring relevance of PNE to individual needs. Studies also propose that PNE in conjunction with either therapeutic exercise or manual therapy may yield significant reduction in pain ratings.[24]

References

  1. ↑ Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Finnerup NB, First MB, Giamberardino MA, Kaasa S, Kosek E, Lavand'homme P, Nicholas M, Perrot S, Scholz J, Schug S, Smith BH, Svensson P, Vlaeyen JWS, Wang SJ. A classification of chronic pain for ICD-11. Pain. 2015 Jun;156(6):1003-7.
  2. ↑ Raffaeli W, Tenti M, Corraro A, Malafoglia V, Ilari S, Balzani E, Bonci A. Chronic Pain: What Does It Mean? A Review on the Use of the Term Chronic Pain in Clinical Practice. J Pain Res. 2021 Mar 29;14:827-35.
  3. ↑ Jackson T, Thomas S, Stabile V, Han X, Shotwell M, McQueen K. Prevalence of chronic pain in low-income and middle-income countries: a systematic review and meta-analysis. Lancet. 2015 Apr 27;385 Suppl 2:S10.
  4. ↑ Sá KN, Moreira L, Baptista AF, Yeng LT, Teixeira MJ, Galhardoni R, de Andrade DC. Prevalence of chronic pain in developing countries: systematic review and meta-analysis. Pain Reports. 2019; 4(6):p e779.
  5. ↑ Nahin RL, Feinberg T, Kapos FP, Terman GW. Estimated Rates of Incident and Persistent Chronic Pain Among US Adults, 2019-2020. JAMA Netw Open. 2023 May 1;6(5):e2313563.
  6. ↑ Rometsch C, Martin A, Junne F, Cosci F. Chronic pain in European adult populations: a systematic review of prevalence and associated clinical features. Pain. 2025; 166(4):719-31.
  7. ↑ Mills SEE, Nicolson KP, Smith BH. Chronic pain: a review of its epidemiology and associated factors in population-based studies. Br J Anaesth. 2019 Aug;123(2):e273-83.
  8. ↑ Nijs J, Girbés EL, Lundberg M, Malfliet A, Sterling M. Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Man Ther. 2015 Feb;20(1):216-20.
  9. ↑ 9.0 9.1 9.2 Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines. Man Ther. 2011 Oct;16(5):413-8.
  10. ↑ Nijs J, George SZ, Clauw DJ, Fernández-de-Las-Peñas C, Kosek E, Ickmans K, Fernández-Carnero J, Polli A, Kapreli E, Huysmans E, Cuesta-Vargas AI, Mani R, Lundberg M, Leysen L, Rice D, Sterling M, Curatolo M. Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine. Lancet Rheumatol. 2021 May;3(5):e383-e392.
  11. ↑ Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain. 2009 Sep;10(9):895-926.
  12. ↑ den Boer C, Terluin B, van der Wouden JC, Blankenstein AH, van der Horst HE. Tests for central sensitization in general practice: a Delphi study. BMC Fam Pract. 2021 Oct 19;22(1):206.
  13. ↑ 13.0 13.1 Moseley GL. Reconceptualising pain according to modern pain science. Phys Ther Reviews. 2007 Sep 1;12(3):169-78.
  14. ↑ 14.0 14.1 14.2 Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011 Dec;92(12):2041-56.
  15. ↑ PAINWeek. Pain Neuroscience Education. Available from:https://www.youtube.com/watch?v=6RGP_usIbBU (accessed 31.10.2024)
  16. ↑ Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education for the management of individuals with chronic low back pain: A systematic review and meta-analysis. Man Ther. 2011 Dec;16(6):544-9.
  17. ↑ Salazar-Méndez J, Cuyul-Vásquez I, Ponce-Fuentes F, Guzmán-Muñoz E, Núñez-Cortés R, Huysmans E, Lluch-Girbés E, Viscay-Sanhueza N, Fuentes J. Pain neuroscience education for patients with chronic pain: A scoping review from teaching-learning strategies, educational level, and cultural perspective. Patient Educ Couns. 2024 Jun;123:108201.
  18. ↑ Louw A, Puentedura EJ, Diener I, Zimney KJ, Cox T. Pain neuroscience education: Which pain neuroscience education metaphor worked best?. S Afr J Physiother. 2019 Aug 13;75(1):1329.
  19. ↑ Watson JA, Ryan CG, Cooper L, Ellington D, Whittle R, Lavender M, Dixon J, Atkinson G, Cooper K, Martin DJ. Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis. J Pain. 2019 Oct;20(10):1140.e1-1140.e22.
  20. ↑ Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine. 2014; 39(18):1449-1457.
  21. ↑ Zimney K, Louw A, Puentedura EJ. Use of Therapeutic Neuroscience Education to address psychosocial factors associated with acute low back pain: a case report. Physiother Theory Pract. 2014 Apr;30(3):202-9.
  22. ↑ Ma X, Chen R, Li W, Huang P. A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: short-term outcomes of pain and disability. Physiother Theory Pract. 2024 Sep;40(9):2130-2149.
  23. ↑ Watson JA, Ryan CG, Cooper L, Ellington D, Whittle R, Lavender M, Dixon J, Atkinson G, Cooper K, Martin DJ. Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis. J Pain. 2019 Oct;20(10):1140.e1-1140.e22.
  24. ↑ Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016 Jul;32(5):332-55.
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